Project Summary/Abstract Acute respiratory distress syndrome (ARDS) is a diffuse lung injury resulting in impaired gas exchange and patients require mechanical ventilation for support. ARDS is associated with very high morbidity, mortality, and healthcare cost. The approach to mechanical ventilation in patients with ARDS matters substantially. Lung protective low tidal volume ventilation (LTVV) is associated with the best patient outcomes. Despite overwhelming evidence that lung protective LTVV is the preferred approach to mechanical ventilation in patients with ARDS, too many patients with ARDS do not receive it. The goal of the proposed research is to pair clinical effectiveness researchers with implementation science researchers in order to conduct a study to determine barriers and facilitators to best evidence-based practices for mechanical ventilation of patients with ARDS. After barriers and facilitators to implementation of lung protective LTVV in patients with ARDS are determined, this proposed research will develop strategies for interventions to improve compliance. Intermountain Healthcare has created a computerized clinical decision support tool for lung protective mechanical ventilation. This tool has been deployed at 12 Intermountain Healthcare hospitals with 17 intensive care units for management of all patients with acute respiratory failure requiring mechanical ventilation. This lung protective LTVV clinical decision support tool has been deployed for use in all mechanically ventilated patients and left up to physician discretion to implement. The strongest evidence for lung protective LTVV is in patients with ARDS. The focus of this proposed study will be to characterize the group of patients with ARDS among mechanically ventilated patients at Intermountain Healthcare and determine strategies to improve compliance with lung protective LTVV in those patients using the computerized electronic decision support tool. In the brief time of implementation, utilization of the computerized clinical decision support tool for mechanically ventilated patients has been highly variable. Creation of a clinical decision support tool alone is unlikely to change clinical practice of adopting LTVV. This proposed study will focus on implementation of lung protective LTVV in patients with ARDS at Intermountain Healthcare hospitals using the clinical decision support tool. Barriers and facilitators associated with implementation of the lung-protective computerized mechanical ventilation clinical decision support for patients with ARDS will be identified. The Consolidated Framework for Implementation Research will be used to guide development of a ventilation protocol implementation strategy that will be tested during a subsequent hybrid effectiveness-implementation trial. The specific aims of this proposed study are to characterize the baseline characteristics of patients with ARDS at Intermountain Healthcare hospitals and assess barriers and facilitators to ideal clinical care delivery of LTVV and then to derive and test an implementation plan for feasibility to achieve LTVV for all patients with ARDS.